Richard Smith on scaling up to defeat childhood obesity

December 7, 2009

Some three million children in Britain are obese, and treating childhood obesity is far from easy. To have any chance of responding adequately to the epidemic of obesity we need to find, firstly, a treatment that works and, secondly, a way to scale it up so that it can be delivered efficiently. Both problems are hard, but the scaling up is, I suggest, the harder problem. I was therefore impressed to encounter an organisation in the backstreets of Southwark that is making real progress with both problems—and already beginning to work not only in Britain but also across the globe.

MEND (Mind, Exercise, Nutrition, Do it!) is a social enterprise that is research driven and has developed a family and community based treatment for childhood obesity. The treatment has been shown in a randomised trial to be published in Obesity next year to reduce waist circumference and body mass index and to increase cardiovascular fitness, physical activity, and self esteem.

The treatment comprises advice on behaviour change, nutrition, and physical activity. There are 18 two hour sessions delivered over ten weeks by two trained leaders and an assistant to groups of 8-15 children with their parents, carers, and siblings. The sessions happen in leisure centres, schools, and other community venues; and there are eight on behavioural change, eight on nutritional advice, and 16 with physical activity. The treatment is highly standardised with training for the leaders, theory and exercise manuals, children’s handouts, programme resources, and teaching aids. There is detailed guidance on how to run each session.

Childhood obesity is concentrated in poorer neighbourhoods, and MEND is committed to promoting health equity. Of the children in the trial half were from ethnic minorities and two thirds came from families where the parent or parents were unemployed or doing manual jobs.

Having designed an effective intervention, MEND has developed a technology platform to scale it up. The internet based Operations Management Monitoring System (OMMS). This makes it easy for the programme manager to organise and monitor the programme and for the MEND team to quality assure the programmes and to gather data on all the participants in the programmes. Some 17 people, mostly in India, have been involved in writing the software and running the system.

It’s this scaling up that most public health programmes don’t manage and makes MEND so important. Programmes are now running at some 350 programmes across the country—some paid for by primary care trusts and some sponsored. Each extra programme means that the unit cost of service delivery (total costs divided by number of programmes) goes down, making scaling ever easier. MEND has data on some 12 000 children and have found results similar to those in the randomised trial—and importantly many of the children are still from deprived backgrounds.

Childhood obesity is a global problem, even co-existing in poor countries with undernutrition, and MEND has work underway in Denmark, Australia, and US. The latter two are the “fattest” countries in the world, and the US has 25 million obese children.

Another important challenge for scaling up is selecting the right business model. That can’t be research grants as research funders are not in the business of implementing the results of the research they fund on a large scale, although perhaps they should be. Depending on sponsorship is fickle, and sponsorship rarely goes on for long. The best model is to serve organisations and people who value what you have to offer and will pay you for it. This approach motivates both the quality and range of public health services made available. A virtuous circle can be generated as increased revenue from delighted customers is reinvested in service improvements.

MEND has successfully demonstrated a sustainable, scalable model but a significant task still lies ahead. If 15 000 children in Britain have been treated that leaves 2 985 000 who haven’t—and there are hundreds of millions in the rest of the world. As Lord Darzi suggests, preventative health services, like those offered by MEND, need to be commissioned at an industrial scale if we are to respond effectively to the chronic disease burden.

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